Registration

Student Registration Form

First Name (English & Chinese)

Last Name (English & Chinese)

Sex

Female

Male

Name of Regular School Attended

Grade Level

Home Address

Home Phone

Mother's Name

Work #

Cell #

WeChat ID (optional)

Father's Name

Work #

Cell #

WeChat ID (optional)

Local Emergency Contact (other than parent/guardian):

Name

Child's Physician

Medical Insurance Carrier

Phone

Location

Policy or Group ID #:

In the event your child gets an accidental injury during our program, we will notify the parent immediately. If emergency treatment is necessary, we will notify the parent immediately and/or call 911 or take the child to the nearest hospital. We may also notify the physician listed on the medical information. Any expenses incurred for the above actions will be the responsibility of the parent, not the school and its staff.

I hereby authorize the after school program and its staff members to take full charge of any emergency that may possibly occur. I will not hold the school and any staff member liable in case of accidents or injuries.

Comments:

Parent E-signature

Date

Participant's E-Signature

Participant's Age

Date

Parent/Guardian E-Signature (If under 18 years old, parent/guardian must also sign)

Date

Student Registration Form

Upon submitting this form, please mail a $35 registration fee to 306 Laurens Way, Chapel Hill, NC 27516.

Please make the check payable to ASAC.